Team Lead Clinical Documentation Integrity (CDI)

Cayuga Health and its affiliates are the region's leading healthcare system and most trusted providers of integrated health services, empowering our people in our mission to equitably improve the well-being of the communities we serve. Our commitment to providing extraordinary healthcare begins with our team of extraordinary professionals who are continuously discovering clinical innovations and enhancing access to the most up-to-date facilities, equipment, technologies, and research protocols. Cayuga Health's commitment to our employees includes competitive compensation, comprehensive employee benefits programs, and the opportunity to explore and build a career in healthcare through our many professional development programs.

Team Lead Clinical Documentation Integrity (CDI)

The RN Clinical Documentation Integrity (CDI) Team Lead will oversee the daily operations of the Clinical Documentation Integrity team across Cayuga Health Health, and Centralus as assigned, ensuring accurate and compliant documentation within the patient's medical record and elsewhere as indicated. This role is crucial in enhancing the quality of clinical documentation by working closely with physicians, nurses, and other healthcare providers to ensure that all documentation is complete, accurate, and reflective of the care provided to patients. The team lead will also mentor and support CDI staff, ensure adherence to coding and regulatory standards, and collaborate wit

Roles And Responsibilities

Leadership & Supervision:

• Supervise and provide leadership to the CDI team, ensuring effective and efficient operations.
• Mentor and support CDI specialists, offering guidance on documentation practices, and addressing team challenges.
• Collaborate with healthcare providers to improve clinical documentation practices, in alignment with coding standards, ensuring appropriate and thorough documentation of patient conditions and treatments.
• Lead the review and analysis of clinical documentation for accuracy, completeness, and compliance with federal, state, and payer regulations.
• Review payer DRG Validation Audit findings resulting in DRG/SOI downgrades for appropriateness and develop processes for appeal based on documentation found in the medical record, evidence-based practice, ICD-10-CM Official Guidelines for Coding and Reporting and New York State Regulations.
• Track and trend targeted audit diagnoses, findings, and appeal results and develop and implement education strategies to minimize DRG/SOI downgrades.
• Communicate with physicians and healthcare providers to resolve documentation discrepancies and clarify clinical information as needed.
• Exemplify satisfactory attendance and punctuality record as set forth by CHS/Centralus policy.
• Exemplify a professional image in appearance, manner and presentation.
• Maintains patient confidentiality in the provision of quality care.
  
  

Quality Improvement

• Analyze documentation trends and collaborate with CDI Leadership team to implement improvements.
• Identify areas for education and training for the CDI team and healthcare providers based on data findings.
• Support clinical staff in understanding the importance of complete, accurate documentation for optimal Supervise and provide leadership to the CDI team, ensuring effective and efficient operations.
  
  

Education/Training & Collaboration

• Provide ongoing education to CDI staff and healthcare providers on clinical documentation best practices and coding guidelines.
• Stay updated on changes in clinical documentation standards, coding systems, and healthcare regulations to ensure team compliance.
• Demonstrates and promotes teamwork and the ability to remain flexible and re-prioritize to cover staffing changes or gaps. Maintains high visibility among the team while readily accessible to staff, providers, coding, and nursing.
• Work closely with other healthcare departments (coding, quality, patient safety, and case management) to ensure optimal documentation standards are being met.
• Act as a liaison between the CDI team, physicians, coding/HIM, and nursing leadership to facilitate collaboration and resolve documentation issues.
• Positively and effectively serves on hospital/system committees as assigned.
  
  

Compliance & Reporting

• Ensure documentation practices comply with regulatory requirements (CMS, Joint Commission, AHIMA/ACDIS/ICD-10 Guidelines, etc.).
• Maintain accurate records of CDI activities, tracking progress on improvement initiatives and documentation audits.
• Monitor and prepare reports on team performance, trends, and outcomes to leadership.
  
  

Required Skills And Experience

Education/Licensure - Registered Nurse (RN) with an active state nursing license. Bachelor's degree in nursing (BSN) preferred. Certified Clinical Documentation Specialist (CCDS) or other relevant certification preferred.

Experience - Minimum 2 to 3 years' experience in an acute care CDI role. Knowledge of federal, state and accreditation standards. Requires strong verbal and written communication, organizational, interpersonal, critical thinking and problem solving skills. Must be able to work in a team environment and exhibit flexibility and enthusiasm in learning new information and developing new skills quickly. Knowledge of pertinent Federal, State, and local laws, codes, and regulations.

Physical Requirements

• Ability to stand, sit or ambulate for long periods. Ability to mobilize freely around units, transport self to site locations, and perform required data entry into EMR and alternate data management systems.
  
  

Location and Travel Requirements:

• Onsite
  
  

Pay Range Disclosure

• $83,280 to $98,280 per year
  
  

Cayuga Health System and its affiliates are committed to treating all patients, providers, staff and volunteers equitably and with dignity, ensuring the highest levels of safety, care and respect, and striving to recognize and overcome biases and policies that contribute to disparities in healthcare access, equitable care and positive health outcomes for all.

We are proud to be an Equal Employment Opportunity employer, supporting the growth and health of our employees and community by embracing the rich diversity, needs and circumstances of all peoples and prioritizing opportunities to build a diverse and inclusive workplace. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable protected characteristics.

If you require reasonable accommodation to complete a job application, pre-employment testing, a job interview or to otherwise participate in the hiring process, please contact the Cayuga Health Talent Acquisition team at talentacquisition@cayugahealth.org.

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